Red Flags
- Haemodynamically unstable AF (hypotension, ischaemic chest pain, acute heart failure) — emergency electrical cardioversion[1]
- AF with pre-excitation (WPW pattern) and rapid ventricular response — avoid AV-node blockers; use procainamide or DC cardioversion[1]
- New ischaemic stroke or TIA in patient with AF — start anticoagulation per timing guidance after exclusion of haemorrhage[1]
- AF with valvular heart disease (moderate-to-severe mitral stenosis or mechanical valve) — DOACs contraindicated; warfarin only[1]
First-line treatment
Interventions
- Catheter ablation (pulmonary vein isolation)[1]Offer for symptomatic paroxysmal or persistent AF where drug treatment unsuccessful, not tolerated, or declined; first-line option for some symptomatic patients per shared decision making
- Left atrial appendage occlusion (LAAO)[1]Consider if AF with high stroke risk and contraindication to long-term anticoagulation
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Apixaban[1] | DOAC (factor Xa inhibitor) | 5 mg PO BD; reduce to 2.5 mg BD if any 2 of: age ≥80, weight ≤60 kg, creatinine ≥133 µmol/L | — | DOAC preferred over warfarin in non-valvular AF per NICE 2021 update |
| Edoxaban[1] | DOAC (factor Xa inhibitor) | 60 mg PO once daily; 30 mg if eGFR 15–50, weight ≤60 kg, or concomitant ciclosporin/dronedarone/erythromycin/ketoconazole | — | Once-daily alternative DOAC |
| Warfarin[1] | Vitamin K antagonist | Titrate to INR 2–3 (mechanical mitral valve: 2.5–3.5) | — | First-line in moderate–severe mitral stenosis or mechanical valves where DOACs contraindicated |
| Bisoprolol[1] | Beta-blocker (cardioselective) | 2.5–10 mg PO once daily; titrate to resting heart rate <110 (lenient) or <80 (strict if symptomatic) | — | First-line rate control. Atenolol or metoprolol succinate are alternatives |
| Diltiazem[1] | Non-DHP calcium channel blocker | 120–360 mg PO daily (sustained-release) | — | Rate control alternative when beta-blockers contraindicated. AVOID in HFrEF |
| Flecainide[1] | Class IC antiarrhythmic | 50–150 mg PO BD; 'pill-in-pocket' 200–300 mg single dose for selected paroxysmal AF without structural heart disease | — | Rhythm control in structurally normal heart; contraindicated with ischaemic or structural heart disease |
Apixaban[1]
DOAC (factor Xa inhibitor)
- Adult
- 5 mg PO BD; reduce to 2.5 mg BD if any 2 of: age ≥80, weight ≤60 kg, creatinine ≥133 µmol/L
- Paediatric
- —
DOAC preferred over warfarin in non-valvular AF per NICE 2021 update
Edoxaban[1]
DOAC (factor Xa inhibitor)
- Adult
- 60 mg PO once daily; 30 mg if eGFR 15–50, weight ≤60 kg, or concomitant ciclosporin/dronedarone/erythromycin/ketoconazole
- Paediatric
- —
Once-daily alternative DOAC
Warfarin[1]
Vitamin K antagonist
- Adult
- Titrate to INR 2–3 (mechanical mitral valve: 2.5–3.5)
- Paediatric
- —
First-line in moderate–severe mitral stenosis or mechanical valves where DOACs contraindicated
Bisoprolol[1]
Beta-blocker (cardioselective)
- Adult
- 2.5–10 mg PO once daily; titrate to resting heart rate <110 (lenient) or <80 (strict if symptomatic)
- Paediatric
- —
First-line rate control. Atenolol or metoprolol succinate are alternatives
Diltiazem[1]
Non-DHP calcium channel blocker
- Adult
- 120–360 mg PO daily (sustained-release)
- Paediatric
- —
Rate control alternative when beta-blockers contraindicated. AVOID in HFrEF
Flecainide[1]
Class IC antiarrhythmic
- Adult
- 50–150 mg PO BD; 'pill-in-pocket' 200–300 mg single dose for selected paroxysmal AF without structural heart disease
- Paediatric
- —
Rhythm control in structurally normal heart; contraindicated with ischaemic or structural heart disease
Safety-net
- Take anticoagulation every day at the same time — missing doses sharply raises stroke risk; never stop without medical advice[1]
- Sudden weakness on one side, slurred speech, severe headache, or vision changes — call emergency services immediately (possible stroke)[1]
- Watch for unusual bruising, prolonged bleeding, black stools, or bloody urine — contact your clinician promptly[1]
Referral criteria
- Haemodynamically unstable AF (hypotension, ischaemic chest pain, acute heart failure)Emergency department for synchronised electrical cardioversion[1]
- Symptomatic paroxysmal AF despite rate or rhythm-control drug therapyCardiology / electrophysiology for catheter ablation evaluation[1]
- AF with high stroke risk and contraindication to anticoagulationCardiology / electrophysiology for LAAO evaluation[1]
- Suspected AF with no rhythm capture on standard ECG despite symptomsCardiology for extended ambulatory monitoring or implantable loop recorder[1]
Clinical summary
Diagnosis, stroke prevention, and rate/rhythm control of atrial fibrillation in adults, with primary-care-focused decision support.